Can Obsessive Compulsive Disorder be Treated Online ... 441.pdfAcceptability of iCBT for OCD • Acceptability is an important factor likely to affect the wide scale implementation

Can Obsessive Compulsive Disorder be Treated Online?

Results from 3 studies

Bethany M. Wootton

Supervisors: A/Prof. Nickolai Titov & Dr. Blake Dear

Disclosure

• I have no actual or potential conflict of interest in relation to this program/presentation.

The Team at the eCentreClinic …

• Director: Associate Professor Nick Titov

• Deputy Director: Dr. Blake Dear

• The Team:

Luke Johnston Genevieve Schwencke

Dr. Judy Zou Sharon Lu

Dr. Carolyn Lorian Amanda Mullin

Jay Spence Bethany Wootton

Matthew Terides

Overview

• Obsessive-Compulsive Disorder (OCD)

• Barriers to accessing treatment

• Acceptability and efficacy of remote treatment for OCD

– Study 1: Acceptability of iCBT for OCD

– Study 2: Feasibility study

– Study 3: RCT: Internet vs. Bibliotherapy vs. Waitlist Control

– Study 4: Reduced Contact Open Trial

• Future research

• Conclusions

Obsessive-Compulsive Disorder

• Obsessions and Compulsions

– Contamination

– Harming

– Unacceptable thoughts

– Symmetry/Order

• Prevalence: 2% (Australian Bureau of Statistics, 2007)

• Treatment is delayed for many years (Abramowitz 1996)

• Treatment often non-evidence based (Crino, Slade & Andrews, 2005)

Cognitive-Behavioral Treatment for OCD

• Cognitive Behavior Therapy (CBT) is effective in the treatment of OCD

• CBT treatment generally involves:

– Exposure and response prevention (ERP)

– Cognitive techniques to address common cognitive biases

– Behavioral experiments

Study Rosa-Alcazar et al. (2008)

Eddy et al. (2004) Abramowitz (1997)

Effect Size 1.0 1.5 1.2

Barriers to Treatment

• Cost

– Direct

– Indirect

• Perceived stigma

– Family

– Friends

– Therapist

Barriers to Treatment

• Difficulty accessing a psychologist locally

– Geographical Remoteness

– Inconvenient consultation times

• Poor access to evidence-based interventions

– For those who can access a therapist they are most often provided with a non evidence based intervention

Remote treatments overcome

many of these barriers

Internet Based Cognitive Behavior Therapy (iCBT)

• iCBT involves applying best-practice CBT skills in an online format with or without therapist guidance

• Internet based treatment for anxiety and depression are effective

• iCBT studies for OCD treatment are lacking

• Little investigation of the acceptability of this treatment modality

Study Andrews et al. 2010 Cuijpers et al. (2009)

Effect Size 0.9 1.1

Study 1: Acceptability of iCBT for Obsessive-Compulsive

Disorder

Acceptability of iCBT for OCD

• Acceptability is an important factor likely to affect the wide scale implementation of iCBT

• iCBT is acceptable to consumers for other anxiety disorders and depression (Aydos, Titov, & Andrews, 2009; Gun, Titov, & Andrews, 2011; Perini, Titov & Andrews 2008)

• There is little research investigating the acceptability of iCBT for OCD

• An important related point is whether those who find iCBT acceptable are similar to OCD samples more generally

Acceptability of iCBT for OCD: Internet Survey

• Aims:

- Investigate the acceptability of iCBT to consumers with OCD

- Compare those seeking treatment online with existing databases of individuals with OCD

• Method:

- Online survey for individuals with OCD (n = 129)

- Demographic and symptom severity data compared with 2 existing databases:

- National epidemiological survey (n = 297)

- OCD patients from specialist outpatient anxiety clinic (n = 135).


• Measures:

– Kessler 10 item scale (K-10)

– 12 item world health organization disability assessment schedule (2nd Edition) (WHODAS-II)

– Yale Brown Obsessive Compulsive Scale (YBOCS) – Self Report Version

– Obsessive Compulsive Inventory – Revised (OCI-R)



Findings: Similarities between groups

• Internet sample comparable to other groups on demographics

• Significant difference in age:

– National Sample > Anxiety Dis. Clinic and Internet Sample

• Significant difference in gender:

– Anxiety Dis. Clinic > More males than National Sample and Internet Sample.

• Significant difference in education:

– Anxiety Dis. Clinic > Internet Sample > National Sample


Findings: Similarities between groups

• Internet sample reported higher levels of disability than comparative samples

• Significant differences on the K-10

– Internet Sample > Anxiety Dis. Clinic and National Sample

• Significant differences on the WHODAS-II

– Internet Sample > Anxiety Dis. Clinic and National Sample

Category Internet Sample Anxiety Clinic National Sample p-value

K-10 31.9 (8.3) 28.8 (7.4) 20.2 (7.6) .000

WHODAS-II 30.4 (9.9) 26.9 (8.1) 19.4 (8.0) .000


Findings: Similarities with existing literature

• Internet sample reported symptom severity similar to other studies in the literature

• YBOCS-SR: Mean = 22.8 (SD = 4.6)

• OCI-R: Mean = 32.8 (SD = 13.6)

• Unfortunately symptom severity information was not available for comparator groups


Findings: Acceptability

• Participants reported internet based treatments would be highly acceptable

• 86% of respondents indicated that they “definitely would” or “possibly would” try Internet based treatment for OCD

53%

33%

13%

2%


Findings: Perceived advantages of iCBT

• Reduced Time – 68%

• No need to travel to appointments - 63%

• Reduced costs - 60%

• Privacy and anonymity – 56%

• Embarrassment related to face to face treatment - 33%

• Less than 10% of participants identified disadvantages of iCBT


Conclusions:

• Those seeking treatment online appear to be demographically similar and had a similar level of disability to OCD samples seen in 2 comparator groups

• Most patients found iCBT acceptable

• Participants identified a number of advantages of iCBT

• Less than 10% saw any disadvantages for iCBT

This Study indicated that respondents had significant symptoms of OCD and were willing to try Internet treatment

The OCD Program

• An Internet delivered OCD treatment program

– Based on current best practice principles

– Contains cognitive and behavioral components

– 8 lesson program provided in a comic format

– Aims to target all subtypes of OCD

– Brief telephone contact 2x per week

Study 2: An Internet Administered

Treatment Program for OCD: A Feasibility Study

An Internet Administered Treatment Program for OCD: A Feasibility Study

• Aims:

– Is Internet based CBT efficacious for obsessive compulsive disorder?

– Is it an acceptable treatment for participants?

• Method:

– 22 participants

– Treatment program provided over the Internet with minimal therapist support

– 8 week treatment

• Inclusion/Exclusion:

• Measures (pre, post, 3 month follow-up):

- Yale-Brown Obsessive Compulsive Scale (YBOCS)

- Obsessive-Compulsive Inventory - Revised (OCI – R)

- Sheehan Disability Scale (SDS)

Inclusion Exclusion

Aged 18-65 Currently participating in treatment

Australian resident Drug/Alcohol abuse

Score > 16 on the YBOCS History of Psychosis/Mania

Access to Internet and Printer Recent medication changes

Primary diagnosis of OCD Suicidal plans or severe depression


• Symptom reduction on the YBOCS, OCI-R and SDS at pre-, post- treatment, and 3 month follow-up


• Effect sizes:

• Effect sizes calculated using Cohen’s d

• Baseline Observation Carried Forward (BOCF) analysis used

• Effect sizes comparable to face to face outcome studies


Means Effect Sizes

Pre – treatment (n = 21)

Post – treatment (n = 21)

3-month follow–up

(n = 19) Pre - Post Pre – Follow-up

YBOCS 20.9 (5.1) 12.6 (5.3) 13.5 (6.4) 1.5 1.3

OCI-R 28.1 (13.4) 19.0 (14.3) 19.6 (14.8) 0.7 0.6

SDS 16.9 (5.8) 9.7 (7.3) 9.6 (7.7) 1.1 1.1

• Percentage meeting diagnostic criteria on the MINI at pre-, post- treatment and 3 month follow-up


29%

48%

• Percentage reduction on the YBOCS


< 10% improvement 11-30% improvement 31-60% improvement >60% improvement

48%

19%

19%

14%

• Acceptability

– 81% completed the 8 lessons within 8 weeks

– Average number of Lessons complete 7.8

– 100% were either “very” or “mostly satisfied”

– 100% would recommend program to a friend

• Clinician time

– Mean = 86mins (SD = 54.4mins) over 8 weeks


• Conclusions:

– Preliminary evidence to suggest that OCD can be treated online

– Small amount of therapist time is required

– Participants found the program highly acceptable

This study provided encouraging evidence to suggest that OCD can be treated online, requiring only a small amount of therapist time


Study 3: Remote Treatment for OCD: A Randomized

Controlled Trial

Remote Treatment for OCD: A Randomized Controlled Trial

2 main types of remote treatment:

• iCBT

• Bibliotherapy

- Different strengths and weaknesses

- Patients may prefer one to the other

- No studies have compared the two treatment modalities in OCD


• Strengths and Weakness of ICBT and Bibliotherapy

– iCBT

• Remote access

• Cost effective

– Bibliotherapy

• No technical difficulties

• Privacy assured

• Ongoing access to materials


• iCBT research for OCD

Author Effect Size Symptom Reduction Drop Out

Andersson et al. (2012) 1.6 40% 0%

Andersson et al. (2011) 1.6 50% 0%

Wootton et al. (2011)(Study 2)

1.5 40% 0%


• Bibliotherapy research for OCD


Gilliam et al. 2010 - 51% 14%

Moritz et al. 2010 0.6 - 16%

Tolin et al. 2007 0.7 17% 15%

The OCD Course

• A remote treatment package for OCD

– Based on current best practice principles

– Contains cognitive and behavioral components

– 5 lesson program provided in a comic format

– Aims to target all subtypes of OCD

– Used a narrative approach where participants are taken through the course by ‘previous participants’ – rather than didactic approach with a therapist


• Aims:

– Investigate the efficacy of iCBT compared to control

– Investigate the efficacy of Bibliotherapy compared to control

– Is there any difference in efficacy between the two active groups

• Method:

– 52 participants

– Minimal therapist support (telephone twice weekly)



• Criteria were reduced to make the study more ecologically valid

• Measures (pre, post):


- Dimensional Obsessive-Compulsive Scale (DOCS)


Inclusion Exclusion



Access to Internet and Printer History of Psychosis/Mania

Recent medication changes

Suicidal plans or severe depression


• Effect sizes: YBOCS

• Effect sizes comparable to face to face outcome studies


Measure Effect Sizes

YBOCS Pre – treatment Post – treatment Pre – Post (BOCF)

Control (n = 17) 21.1 (5.6) 20.6 (4.8) 0.1

Bibliotherapy (n = 20) 21.8 (5.2) 15.6 (5.5) 1.2

Internet (n = 15) 23.5 (4.9) 16.6 (8.5) 1.0

• Effect sizes: DOCS



DOCS Pre – treatment Post – treatment Pre – Post (BOCF)

Control (n = 17) Total 29.2 (12.0) 29.0 (14.1) 0.0

Main 11.9 (3.1) 10.8 (4.3) 0.3

Bibliotherapy (n = 20) Total 32.2 (17.0) 24.8 (16.6) 0.4

Main 13.2 (3.3) 9.6 (3.6) 1.0

Internet (n = 15) Total 26.7 (10.0) 20.4 (10.5) 0.6

Main 12.1 (3.0) 9.3 (4.8) 0.7

• Effect sizes: SDS



SDS Pre – treatment Post – treatment Pre – Post (BOCF)

Control (n = 17) 16.5 (7.4) 15.2 (7.7) 0.2

Bibliotherapy (n = 20) 15.9 (7.4) 12.4 (8.5) 0.6

Internet (n = 15) 15.9 (8.5) 12.5 (9.3) 0.4

• Percentage meeting diagnostic criteria on the MINI at pre and post- treatment


• Percentage reduction on the YBOCS (BOCF)


Bibliotherapy Internet


47%

13%

33%

7%

• Clinician time

– Bibliotherapy: Mean = 103 mins, SD = 51 mins

– Internet: Mean = 89 mins, SD = 46 mins

• Drop out rates

– Bibliotherapy: 25%

– Internet: 33%


• Acceptability

– Percentage either “very” or “mostly satisfied”

• Bibliotherapy – 73%

• Internet – 78%

– Percentage that would recommend program to a friend

• Bibliotherapy – 93%

• Internet - 100%


• Conclusions

– Preliminary evidence to suggest that OCD can be treated remotely

– Preliminary evidence to suggest that iCBT and Bibliotherapy result in similar outcomes

– Remote treatments are cost effective in terms amount of therapist guidance required

– Automatic reminders appear important in reducing drop out rates

This study provided encouraging evidence to suggest that OCD can be treated online or with bibliotherapy, requiring only a small

amount of therapist time


Study 4: Reduced Contact

An Open Trial

Reduced Contact: An Open Trial

• Aims:

– To investigate the efficacy of iCBT with weekly contact

• Method:

– 11 participants (data collection ongoing)

– Treatment program provided over the Internet with minimal therapist support (1 phone call per week)



• Measures (pre, post):


- Dimensional Obsessive Compulsive Scale (DOCS)


Reduced Contact: Open Trial

Inclusion Exclusion



Access to Internet and Printer History of Psychosis/Mania

Recent medication changes

Suicidal plans or severe depression

• Effect sizes: YBOCS



Pre – treatment Post – treatment Pre – Post (BOCF)

YBOCS 20.5 (5.8) 13.9 (7.7) 1.0

DOCS Total 25.1 (16.1) 17.0 (14.3) 0.5

DOCS Main 11.7 (4.1) 6.7 (5.0) 1.1

SDS 13.3 (7.5) 7.6 (8.4) 0.5

• Percentage meeting diagnostic criteria on the MINI at pre and post treatment (BOCF)


• Percentage reduction on the YBOCS (BOCF)



30%

30%

25%

15%

• Clinician time

– Mean = 63 minutes (SD = 54.5mins) over 8 weeks

• Acceptability

– 70% were either “satisfied” or “extremely satisfied”

– 90% would recommend program to a friend

• Drop out rate

– 9%


• Conclusions

– Large effect sizes can be obtained by just contacting participants once a week

– Automatic reminders appear important for reducing drop out rates and increasing outcomes

This study adds to the emerging evidence to suggest that OCD can be treated remotely, requiring only 60mins of therapist time per participant


General Conclusions

Conclusions:

• Remote treatment for OCD using either iCBT or Bibliotherapy is effective

Study Effect Size Symptom Reduction

Dropout

Study 2 – Open Trial 1.5 40% 0%

Study 3 (Internet) - RCT 1.0 29% 20%

Study 3 (Bibliotherapy) - RCT 1.4 28% 25%


Comparisons with Existing iCBT Studies

• iCBT research for OCD


Andersson et al (2012) 1.6 40% 0%

Andersson et al (2011) 1.6 50% 0%


Study 3 (Internet Group) - RCT

1.0 29% 20%


Comparisons with Existing Bibliotherapy Studies

• Bibliotherapy research for OCD

* Indicates studies using an ITT analysis

Author n Effect Size Symptom Reduction Drop Out

Gilliam et al 2010* 14 - 51% 14%

Moritz et al 2010 43 0.6 - 16%

Tolin et al., 2007* 20 0.7 17% 15%

Study 3 - RCT* 20 1.4 28% 25%

General Conclusions

Conclusions:

• Participants find remote treatment highly acceptable

– Study 2: 100% of participants would recommend the program to a friend

– Study 3 - Bibliotherapy Group: 93% of participants would recommend the program to a friend

– Study 3 – Internet Group: 100% of participants would recommend the program to a friend

– Study 4: - 90% of participants would recommend the program to a friend

General Limitations

Limitations:

• Small sample size

• Open trial design in some studies

• Assessment raters not independent

Future Research

Self Guided Version

• Can the program be administered in a self-guided format?

Administration by non-psychologists

• Can the program be administered by a trained non-therapist

Dissemination and Integration with Face to Face services

• Can the program be used to increase access to evidence based treatment for those seeing a psychologist face to face?

• Can a similar program be used by face to face therapists to assist with preventing relapse?

General Conclusions

• OCD is a common and chronic disorder, which causes considerable disability and impairment

• There are many barriers to accessing evidence based care

• Remote treatments can be used as a way to overcome these barriers

• There is preliminary evidence to suggest that OCD can be successfully treated remotely

• We were surprised by our results, but encouraged by the possibilities that remote treatments holds for improving access to evidence based treatments.

• Further research is required

Can Obsessive Compulsive Disorder be Treated Online?

Results from 3 studies

Bethany M. Wootton [email protected]

[email protected]

Thank You….

mailto:[email protected]

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Documents

Can Obsessive Compulsive Disorder be Treated Online ... 441.pdfAcceptability of iCBT for OCD • Acceptability is an important factor likely to affect the wide scale implementation